Original article
Short-term morbidity and mortality of Indiana pouch, ileal conduit, and neobladder urinary diversion following radical cystectomy

https://doi.org/10.1016/j.urolonc.2014.04.009Get rights and content

Abstract

Purpose

Literature surrounding Indiana pouch (IP) urinary diversion suggests a higher incidence of complications and longer operative time compared with ileal conduit (IC) and neobladder (NB). We sought to assess short-term complications of IP diversions compared with other diversions at our institution.

Materials and methods

Using institutional National Surgical Quality Improvement Program data, we identified radical cystectomy cases performed for bladder cancer at Indiana University from January 2011 until June 2013. During this time period, the National Surgical Quality Improvement Program randomly evaluated approximately 70% of radical cystectomies performed for urothelial carcinoma at our institution. Multivariable logistic regression was performed to identify factors associated with Clavien grade III–V complications.

Results

A total of 233 cases were identified, 139 IC, 39 IP, and 55 NB. Mean (standard deviation) operative times for IC, IP, and NB were 257 (84), 383 (78), and 327 (88) minutes, respectively (P<0.001). Half of the patients required blood transfusion during the hospitalization. The overall rate of complications was significantly lower among NB (P = 0.009). Overall, 12% of patients developed a Clavien grade III–V complication, with no difference observed between groups (P = 0.884). After controlling for preoperative confounders, IP patients were not at increased odds of developing a Clavien III–V complication compared with IC (odds ratio = 1.38, P = 0.599).

Conclusions

At a high-volume center, the incidence of serious complications was similar between diversion types. IP patients were more likely to experience minor complications. Patients should be counseled regarding rates of short-term complications and blood transfusion.

Introduction

Urinary diversion following radical cystectomy is classified as incontinent or continent, with continent forms reserved for patients who have normal renal and hepatic function along with the mental and physical capacity to self-catheterize. The most common methods of continent diversion are orthotopic neobladder (NB) and continent urinary reservoir, also known as the Indiana pouch (IP). These methods for continent diversion have been regularly used since the 1980s [1], [2]. Many urologists prefer the NB over the IP to avoid stoma creation, to potentially reduce long-term complications with catheterization or stone formation, and to decrease operative times [3], [4]. Despite improvements in radical cystectomy with urinary diversion techniques, less than 20% of patients in contemporary national cohorts undergo continent diversion [5], [6]. In spite of the national data, individual high-volume institutions have reported rates of continent diversion closer to 40% although there is a trend toward decreased use of continent diversion among lower-volume surgeons [3], [7].

Perioperative morbidity is relatively high in radical cystectomy patients ranging from 30% to 60% in the literature [8], [9], [10], [11]. The cause of this is likely multifactorial; radical cystectomy patients have an aggressive malignancy, multiple comorbidities, and undergo an extensive procedure that not only involves surgical extirpation but also includes bowel reconstruction for urinary transport and storage [9]. Studies have noted mortality in 1% to 3% of patients, deep vein thrombosis (DVT) or pulmonary embolism (PE) in 3% to 5%, and fascial dehiscence in 5% to 9% of urinary diversion patients [6], [10], [12].

We hypothesized that when performed at a high-volume academic institution, there would be no difference in the incidence of perioperative complications between the diversion types. Recognizing that our institution performs a large number of cystectomies with urinary diversion each year, we sought to compare 30-day postoperative complication rates between diversion types using institutional data from the National Surgical Quality Improvement Project (NSQIP).

Section snippets

Data and inclusion criteria

NSQIP is a validated system created by the American College of Surgeons and has enrolled nonfederal hospitals since 2004 to aid hospitals in systematic tracking of 30-day postoperative morbidity and mortality [13]. NSQIP data are collected in a uniform fashion by trained Surgical Clinica Reviewers who collect standardized preoperative and 30-day postoperative data for each randomly selected case. The data include details on the index operation and subsequent operations within the 30-day

Results

There were 233 patients identified for inclusion. Mean age of radical cystectomy patients was 67.7 years [11], and 20% of patients were women. Mean BMI was 28. The mean preoperative creatinine value for all patients undergoing diversion was 1.2 ng/mL (Table 1). A total of 139 patients underwent IC diversion, 39 patients (17%) IP, and 55 (23%) NB. Patients undergoing NB and IP were younger than IC patients (P<0.001), but there were no differences in sex or race distributions between the groups.

Discussion

At a high-volume institution with approximately 200 cystectomies performed on average each year, we did not find increased odds of 30-day postoperative severe complications for patients undergoing IC, IP, or NB. Higher incidence of Clavien I and II complications were observed in the IP population. The differences in complications between the diversion types may not be surprising, given the high volume of cystectomies performed annually at our institution.

Previous studies have demonstrated high

Acknowledgment

The authors thank Molly Kilbane, the NSQIP surgical clinical reviewer at our hospital, whose hard work and dedication to the ideals of NSQIP enabled the current project.

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